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Practitioner Question of the Month – August 2017

Dr. Michael Ruscio’s Monthly – Future of Functional Medicine Review Clinical Newsletter

Practical Solutions for Practitioners

Practitioner Question of the Month - August 2017 - help circle

Practitioner Question of the Month

Susan B. says: “What are your thoughts on using PTH levels to determine if Vit D supplementation is warranted? Is there a concern for Vit D toxicity if supplementing without any testing?”

Good question Susan. Regarding using PTH, this is not something I do.

If you have not seen my interview with Dr. Chris Masterjohn, please see here for more on this topic, He essentially suggests keeping PTH in the lower half of the reference range, roughly <35pg/mL.

Why don’t I do this? Well, I am perfectly open to this. However, I do not feel we need to be incredibly meticulous with our vitamin D testing and treatment for a few reasons:

  • Some trials suggest that vitamin D is a marker of ill health and this may be why we do not see consistent benefit when supplementing vitamin D in various conditions where the subjects also have low vitamin D.
  • In the small number of trials in autoimmune conditions, we see vitamin D shows benefit using somewhat lower and conservative doses of vitamin D, around 2,000 IUs per day, wherein the dosing was not based upon testing.
  • Obtaining safe sun exposure should be focused on, rather than a pill supplement, to improve vitamin D levels. In practice, it can be very difficult to micromanage someone’s sun exposure to achieve the perfect level of vitamin D or PTH. It’s more practical for someone to create a habit of weekly or even daily sun exposure that works for their skin type and where they reside.

Yes, in my opinion you can supplement safely without much testing required, if:

  • You are focusing on sun exposure during the sunny months, and
  • Using a reasonable dose of vitamin D in the non-summer months, around 2,000 IUs per day or less.

It is still a good idea to test periodically early on to ensure vitamin D levels are not becoming too high; 1-2 times per year.

Finally, if you have other conditions and diseases you are working toward correcting (SIBO, IBS, IBD, Hashimoto’s, Graves’, insomnia, female hormone imbalances…) the focus on these conditions often takes precedence, in my opinion. We can still use vitamin D and sun exposure in these cases of course, but there are often other more pressing tests/treatments to monitor in these cases.

Practitioner Question of the Month - August 2017 - practice tip

Practice Tip

Why you should be staggering the initiation of your interventions.

Overtreatment is a major obstacle in functional medicine. It leads to poor patient compliance, a high level of expense, and detracts from the clinician’s ability to discern what the most effective treatments are. One effective method for preventing overtreatment is to stagger your interventions. This means instead of having a patient start all interventions at once, they wait a few weeks in between so as to be able to report a given level of benefit for each treatment individually.

You will start to see this reflected in my case studies in the future, but here is an example of what this might look like. You have a patient with IBS who you think may benefit from probiotics and the low FODMAP diet. In order to establish how helpful each of these interventions will be, you instruct the patient to do the following:

‘Be on the low FODMAP diet for 3 weeks, then add in the probiotic protocol, and then follow up after being on the probiotic protocol for 3 weeks (6 weeks from now). Make a note of any changes you notice from the diet and then from the supplements so we can determine the benefit of each of these.’

Then when the patient/client follows up, you can get an account for how effective each intervention was or wasn’t. If someone says, “I felt no different on the low FODMAP diet but felt noticeably improved on the probiotics…,” then you can instruct them to discontinue the diet. Or, vice versa. By incorporating this strategy, you can build personalized patient treatment programs that provide minimal intervention and maximal benefit.

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I’d like to hear your thoughts or questions regarding any of the above information. Please leave comments or questions below – it might become our next practitioner question of the month.


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